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When Tufts University psychiatrist Manuel Pacheco, MD, sees his patients these days, it’s sometimes from his dining room table at home. His patients might be huddled in their car or perched at their own dining room table. He may get a glimpse of their cat or hear their dog while they’re talking together by video conference. The neutral, businesslike office with a couch is gone. And Pacheco is delighted.
“I can tell you, qualitatively, that it enhances [the doctor/patient relationship], I think exponentially, because the person is in their own domain in their own place,” Pacheco, the chief of consultation in psychiatry at Tufts University School of Medicine, Boston, Massachusetts, told Medscape Medical News.
Although it would be difficult to prove that the COVID-19 pandemic has changed the therapeutic alliance — the term for the patient/therapist relationship — several mental health therapists from Seattle to Boston say they perceive a shift for at least some of their patients.
They give the video consult a thumbs-up for widening access and sometimes providing a literal “window” into a patient’s life, which enriches the dialogue. However, they also note there is a potential downside of telepsychiatry ― the potential to exacerbate healthcare disparities for patients who don’t have reliable internet or who aren’t tech savvy.
Some psychiatrists were already using telehealth methods —video, telephone, or both — to interact with their patients before the COVID-19 pandemic, but according to a policy statement issued last June by the American Psychiatric Association (APA), now about 85% of visits are conducted via telemedicine.
Greg Simon, MD, MPH, a psychiatrist and senior investigator with the Kaiser Permanente Washington Health Research Institute in Seattle, Washington, remembers when it all shifted last March. Reimbursement changes and pandemic protocols that limited in-person visits forced his practice onto the computer or phone in a matter of days.
“It was one weekend in March. We went from essentially an in-person bricks-and-mortar mental health care system to a virtual care system,” Simon said. Since that initial period, the system has flexed to a hybrid in which some patients come to clinics and others prefer video or phone visits.
To minimize the risk of spreading COVID-19, states, the US Department of Health and Human Services, private insurers, and the Drug Enforcement Administration all made temporary changes to regulations and reimbursement to make telemedicine visits more widely available.
Pacheco hopes the shift and the reimbursement for video and phone visits will continue. He’s on an APA committee that’s endorsed that shift in reimbursement to be permanent.
“I can hear their cat or their dog. Even on telephone visits, you can kind of hear how the patient lives…. So it really helps you to have increased access to your patient,” Pacheco says.
Simon described one example of the benefit of seeing into a patient’s home. The patient had talked about feeling lonely and lacking hobbies that could fuel social relationships. While on video, Simon saw guitars hanging on the wall behind him. It opened up a new discussion of music and the patient’s passion for it and how that might benefit him socially.
In New York City, Jihan Ryu, MD, a resident at the Icahn School of Medicine at Mount Sinai, saw one of his patients while she was cooking dinner for her family. Some patients who have roommates take a laptop out to their car to find privacy. One of Ryu’s patients hid in a closet to ensure privacy from a partner.
“This has to be my favorite part of doing telehealth — you shift the focus of clinical space from me to her or him. It is huge,” Ryu says. “You are not waiting for them to show up to your space and sit on the couch.”
Ryu is conducting research on biometric measurements of faces and voices to try to “measure” the therapeutic relationship as it relates to patient outcomes.
Although telemedicine visits may improve access for some patients ― those who don’t need to take two buses or brave parking shortages to reach a clinic ― it can also make those who do not have reliable internet service or technology skills feel left out and uncomfortable.
Ryu questions whether this shift could worsen systemic disparities by cutting off the support system for patients who don’t have tech fluency.
“Poor people don’t have technology access, or they might not know how to click ‘mute’ or find the tech too complicated. They need to figure out their next meal. But they are the ones I want to provide therapy for,” he says.
In spring 2020, a survey queried 20 psychiatrists about “suddenly becoming a virtual doctor.” The study, published in Psychiatric Services, revealed many concerns, although it described the transition to telehealth during the pandemic as “largely positive.”
Participants listed limitations such as diminished patient privacy, increased distractions in the home environment, the lack of reliable internet or smartphone technology, as well as less complete views of new patients for intake assessments.
Hybrid Model the Way of the Future?
Clinical social worker Amy Lopez, PhD, who researches internet-based mental health treatment at the University of Colorado’s Helen and Arthur E. Johnson Depression Center, in Aurora, Colorado, says telehealth offers another way therapists can support patients, whether it’s via email, text messaging, video conferencing, or phone calls.
“I think there’s more flexibility and all this extra space that is outside the hour. And that’s one of the differences of the pandemic — people are reaching out more than they were before,” she says. “There’s more asynchronous interaction to support that hour of therapy.”
She predicts that once the pandemic is over, some therapists will adopt a hybrid model of both in-person therapy and teletherapy.
That kind of asynchronous contact with a patient via text or phone or video conference should all be part of a consultation, the APA notes in its policy statement, which includes a long list of recommended guidelines and reimbursement changes that it hopes will become permanent.
The APA is also calling for research to gain an understanding of the pandemic’s full impact and to document and measure all the ways it is changing barriers and driving innovation in what it describes as the landscape of healthcare delivery.
Some patients want to visit clinics, but Simon points out a few ways that in-person sessions are strange now. When he wears personal protective equipment, including a mask, his patient can’t see much of his face.
Hearing his voice through the mask is also challenging for some of his patients, who may have a problem hearing that’s been underestimated because they rely on lipreading, he says.
With the exception of observing a patient physically and noticing tremors or side effects from medications, Simon believes the in-person visit can be essential.
“Sometimes you just really have to see somebody in person to sort that out,” he says.